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Factors that affect cost and clinical outcome of endovascular aortic repair for abdominal aortic aneurysm
Abstract Objective This study evaluated the effect of indication for use (IFU), additional graft components, and percutaneous closure of endovascular aortic repair (PEVAR) on clinical outcomes and cost of endovascular aortic repair (EVAR). Methods Clinical and financial data were obtained for all el...
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| Published in: | Journal of vascular surgery 2017-04, Vol.65 (4), p.997-1005 |
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| creator | O'Brien-Irr, Monica S., MS, RN Harris, Linda M., MD Dosluoglu, Hasan H., MD Cherr, Gregory S., MD Rivero, Mariel, MD Noor, Sonya, MD Curl, G. Richard, MD Dryjski, Maciej L., MD, PhD |
| description | Abstract Objective This study evaluated the effect of indication for use (IFU), additional graft components, and percutaneous closure of endovascular aortic repair (PEVAR) on clinical outcomes and cost of endovascular aortic repair (EVAR). Methods Clinical and financial data were obtained for all elective EVARs completed at a university-affiliated medical center between January 2012 and June 2013. Data were analyzed by χ2 , Student t -test for independent samples, and Kaplan-Meier survival. Results There were 67 elective EVARs. Additional cuffs/extensions were used in 37%, increasing the baseline graft cost by 36% ( P < .001), total costs by 20% ( P < .001), and negatively affecting the contribution margin. Aortic neck IFU ( P = .02), failure of the index graft to seal the neck ( P = .02), and need for an additional cuff ( P = .008) were related to the need for reintervention for type Ia endoleak for graft B (Excluder; W. L. Gore and Associates, Flagstaff, Ariz), whereas limb IFU was related to the need for additional limb extension for graft A (Powerlink; Endologix, Irvine, Calif; P < .001). Limb extension ( P = .06) and failure of the index graft to provide an adequate seal ( P < .001) were associated with reintervention for type Ib endoleak. Reintervention-free rates at 24 months were 96% for graft A and 94% for graft B ( P =.54), but different patterns in reintervention emerged: graft A required reoperation early ( |
| doi_str_mv | 10.1016/j.jvs.2016.08.090 |
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Richard, MD ; Dryjski, Maciej L., MD, PhD</creator><creatorcontrib>O'Brien-Irr, Monica S., MS, RN ; Harris, Linda M., MD ; Dosluoglu, Hasan H., MD ; Cherr, Gregory S., MD ; Rivero, Mariel, MD ; Noor, Sonya, MD ; Curl, G. Richard, MD ; Dryjski, Maciej L., MD, PhD</creatorcontrib><description><![CDATA[Abstract Objective This study evaluated the effect of indication for use (IFU), additional graft components, and percutaneous closure of endovascular aortic repair (PEVAR) on clinical outcomes and cost of endovascular aortic repair (EVAR). Methods Clinical and financial data were obtained for all elective EVARs completed at a university-affiliated medical center between January 2012 and June 2013. Data were analyzed by χ2 , Student t -test for independent samples, and Kaplan-Meier survival. Results There were 67 elective EVARs. Additional cuffs/extensions were used in 37%, increasing the baseline graft cost by 36% ( P < .001), total costs by 20% ( P < .001), and negatively affecting the contribution margin. Aortic neck IFU ( P = .02), failure of the index graft to seal the neck ( P = .02), and need for an additional cuff ( P = .008) were related to the need for reintervention for type Ia endoleak for graft B (Excluder; W. L. Gore and Associates, Flagstaff, Ariz), whereas limb IFU was related to the need for additional limb extension for graft A (Powerlink; Endologix, Irvine, Calif; P < .001). Limb extension ( P = .06) and failure of the index graft to provide an adequate seal ( P < .001) were associated with reintervention for type Ib endoleak. Reintervention-free rates at 24 months were 96% for graft A and 94% for graft B ( P =.54), but different patterns in reintervention emerged: graft A required reoperation early (<2 months) then stabilized; graft B did not require reintervention until 24 months, but rates increased substantially by 25 months. PEVAR was attempted in 61 (91%): 49 (73%) bilaterally, 7 (10%) unilaterally, and 5 (8%) failed. The mean number of closure devices was four (range, 1-9): $1000 (3.5% of total cost). Bilateral PEVAR was associated with shorter operating time than unilateral PEVAR/failed PEVAR ( P < .001) and lower operating room use costs ( P = .005) and total hospital costs ( P = .003) than failed PEVAR. The contribution margin was higher for bilateral PEVAR than unilateral PEVAR/failed PEVAR ( P = .005). Patients with bilateral PEVAR and unilateral PEVAR were more often discharged on postoperative day 1 than those with failed PEVAR ( P = .002). Hospital length of stay ( P = .49), operating room duration ( P = .31), and total costs ( P = .72) were similar for unsuccessful PEVAR and EVAR completed with cutdown. Conclusions Higher rates of reintervention occurred when EVAR was performed outside of IFU guidelines or when additional components were needed. Additions raised graft costs significantly above baseline. Notable differences in graft performance in complex anatomy and varied patterns of reoperation could be useful in the graft selection process to improve outcome and contain costs. Bilateral PEVAR was associated with lower costs and postoperative day 1 discharge. Attempting PEVAR may be reasonable unless there is serious concern for failure.]]></description><identifier>ISSN: 0741-5214</identifier><identifier>EISSN: 1097-6809</identifier><identifier>DOI: 10.1016/j.jvs.2016.08.090</identifier><identifier>PMID: 28034587</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Academic Medical Centers - economics ; Aged ; Aged, 80 and over ; Aortic Aneurysm, Abdominal - diagnostic imaging ; Aortic Aneurysm, Abdominal - economics ; Aortic Aneurysm, Abdominal - mortality ; Aortic Aneurysm, Abdominal - surgery ; Blood Vessel Prosthesis - economics ; Blood Vessel Prosthesis Implantation - adverse effects ; Blood Vessel Prosthesis Implantation - economics ; Blood Vessel Prosthesis Implantation - instrumentation ; Blood Vessel Prosthesis Implantation - mortality ; Chi-Square Distribution ; Cost Savings ; Cost-Benefit Analysis ; Disease-Free Survival ; Endovascular Procedures - adverse effects ; Endovascular Procedures - economics ; Endovascular Procedures - instrumentation ; Endovascular Procedures - mortality ; Female ; Hospital Costs ; Humans ; Kaplan-Meier Estimate ; Male ; Middle Aged ; New York ; Postoperative Complications - economics ; Postoperative Complications - etiology ; Postoperative Complications - therapy ; Prosthesis Design ; Retreatment - economics ; Retrospective Studies ; Risk Factors ; Surgery ; Time Factors ; Treatment Outcome</subject><ispartof>Journal of vascular surgery, 2017-04, Vol.65 (4), p.997-1005</ispartof><rights>Society for Vascular Surgery</rights><rights>2016 Society for Vascular Surgery</rights><rights>Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c451t-82a45fe873496ef17fe14d0d6429fcc8bb5302e3d10e6397beaead20d9cb4e873</citedby><cites>FETCH-LOGICAL-c451t-82a45fe873496ef17fe14d0d6429fcc8bb5302e3d10e6397beaead20d9cb4e873</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,780,784,27924,27925</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/28034587$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>O'Brien-Irr, Monica S., MS, RN</creatorcontrib><creatorcontrib>Harris, Linda M., MD</creatorcontrib><creatorcontrib>Dosluoglu, Hasan H., MD</creatorcontrib><creatorcontrib>Cherr, Gregory S., MD</creatorcontrib><creatorcontrib>Rivero, Mariel, MD</creatorcontrib><creatorcontrib>Noor, Sonya, MD</creatorcontrib><creatorcontrib>Curl, G. Richard, MD</creatorcontrib><creatorcontrib>Dryjski, Maciej L., MD, PhD</creatorcontrib><title>Factors that affect cost and clinical outcome of endovascular aortic repair for abdominal aortic aneurysm</title><title>Journal of vascular surgery</title><addtitle>J Vasc Surg</addtitle><description><![CDATA[Abstract Objective This study evaluated the effect of indication for use (IFU), additional graft components, and percutaneous closure of endovascular aortic repair (PEVAR) on clinical outcomes and cost of endovascular aortic repair (EVAR). Methods Clinical and financial data were obtained for all elective EVARs completed at a university-affiliated medical center between January 2012 and June 2013. Data were analyzed by χ2 , Student t -test for independent samples, and Kaplan-Meier survival. Results There were 67 elective EVARs. Additional cuffs/extensions were used in 37%, increasing the baseline graft cost by 36% ( P < .001), total costs by 20% ( P < .001), and negatively affecting the contribution margin. Aortic neck IFU ( P = .02), failure of the index graft to seal the neck ( P = .02), and need for an additional cuff ( P = .008) were related to the need for reintervention for type Ia endoleak for graft B (Excluder; W. L. Gore and Associates, Flagstaff, Ariz), whereas limb IFU was related to the need for additional limb extension for graft A (Powerlink; Endologix, Irvine, Calif; P < .001). Limb extension ( P = .06) and failure of the index graft to provide an adequate seal ( P < .001) were associated with reintervention for type Ib endoleak. Reintervention-free rates at 24 months were 96% for graft A and 94% for graft B ( P =.54), but different patterns in reintervention emerged: graft A required reoperation early (<2 months) then stabilized; graft B did not require reintervention until 24 months, but rates increased substantially by 25 months. PEVAR was attempted in 61 (91%): 49 (73%) bilaterally, 7 (10%) unilaterally, and 5 (8%) failed. The mean number of closure devices was four (range, 1-9): $1000 (3.5% of total cost). Bilateral PEVAR was associated with shorter operating time than unilateral PEVAR/failed PEVAR ( P < .001) and lower operating room use costs ( P = .005) and total hospital costs ( P = .003) than failed PEVAR. The contribution margin was higher for bilateral PEVAR than unilateral PEVAR/failed PEVAR ( P = .005). Patients with bilateral PEVAR and unilateral PEVAR were more often discharged on postoperative day 1 than those with failed PEVAR ( P = .002). Hospital length of stay ( P = .49), operating room duration ( P = .31), and total costs ( P = .72) were similar for unsuccessful PEVAR and EVAR completed with cutdown. Conclusions Higher rates of reintervention occurred when EVAR was performed outside of IFU guidelines or when additional components were needed. Additions raised graft costs significantly above baseline. Notable differences in graft performance in complex anatomy and varied patterns of reoperation could be useful in the graft selection process to improve outcome and contain costs. Bilateral PEVAR was associated with lower costs and postoperative day 1 discharge. Attempting PEVAR may be reasonable unless there is serious concern for failure.]]></description><subject>Academic Medical Centers - economics</subject><subject>Aged</subject><subject>Aged, 80 and over</subject><subject>Aortic Aneurysm, Abdominal - diagnostic imaging</subject><subject>Aortic Aneurysm, Abdominal - economics</subject><subject>Aortic Aneurysm, Abdominal - mortality</subject><subject>Aortic Aneurysm, Abdominal - surgery</subject><subject>Blood Vessel Prosthesis - economics</subject><subject>Blood Vessel Prosthesis Implantation - adverse effects</subject><subject>Blood Vessel Prosthesis Implantation - economics</subject><subject>Blood Vessel Prosthesis Implantation - instrumentation</subject><subject>Blood Vessel Prosthesis Implantation - mortality</subject><subject>Chi-Square Distribution</subject><subject>Cost Savings</subject><subject>Cost-Benefit Analysis</subject><subject>Disease-Free Survival</subject><subject>Endovascular Procedures - adverse effects</subject><subject>Endovascular Procedures - economics</subject><subject>Endovascular Procedures - instrumentation</subject><subject>Endovascular Procedures - mortality</subject><subject>Female</subject><subject>Hospital Costs</subject><subject>Humans</subject><subject>Kaplan-Meier Estimate</subject><subject>Male</subject><subject>Middle Aged</subject><subject>New York</subject><subject>Postoperative Complications - economics</subject><subject>Postoperative Complications - etiology</subject><subject>Postoperative Complications - therapy</subject><subject>Prosthesis Design</subject><subject>Retreatment - economics</subject><subject>Retrospective Studies</subject><subject>Risk Factors</subject><subject>Surgery</subject><subject>Time Factors</subject><subject>Treatment Outcome</subject><issn>0741-5214</issn><issn>1097-6809</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2017</creationdate><recordtype>article</recordtype><recordid>eNp9kUFr3DAQhUVpaLZpf0AvRcde7Ghk2ZYpFEpI0kAgh7ZnIUsjKte2tpK9sP8-MrvpoYee9JDeGzTfI-QDsBIYNNdDORxSybMsmSxZx16RHbCuLRrJutdkx1oBRc1BXJK3KQ2MAdSyfUMuuWSVyHJH_J02S4iJLr_0QrVzaBZqQsp6ttSMfvZGjzSsiwkT0uAozjYcdDLrqCPVIS7e0Ih77SN1Id_0Nkx-zpnzm55xjcc0vSMXTo8J35_PK_Lz7vbHzbfi8en-4ebrY2FEDUshuRa1Q9lWomvQQesQhGW2Ebxzxsi-ryvGsbLAsKm6tkeN2nJmO9OLLXZFPp3m7mP4s2Ja1OSTwXHMHwlrUiBr0UDVAc9WOFlNDClFdGof_aTjUQFTG2E1qExYbYQVkyoTzpmP5_FrP6H9m3hBmg2fTwbMSx48RpWMx9mg9THDVTb4_47_8k_6pYPfeMQ0hDVmtnkLlbhi6vtW8dYwNBUAb3n1DE80orM</recordid><startdate>20170401</startdate><enddate>20170401</enddate><creator>O'Brien-Irr, Monica S., MS, RN</creator><creator>Harris, Linda M., MD</creator><creator>Dosluoglu, Hasan H., MD</creator><creator>Cherr, Gregory S., MD</creator><creator>Rivero, Mariel, MD</creator><creator>Noor, Sonya, MD</creator><creator>Curl, G. Richard, MD</creator><creator>Dryjski, Maciej L., MD, PhD</creator><general>Elsevier Inc</general><scope>6I.</scope><scope>AAFTH</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>20170401</creationdate><title>Factors that affect cost and clinical outcome of endovascular aortic repair for abdominal aortic aneurysm</title><author>O'Brien-Irr, Monica S., MS, RN ; Harris, Linda M., MD ; Dosluoglu, Hasan H., MD ; Cherr, Gregory S., MD ; Rivero, Mariel, MD ; Noor, Sonya, MD ; Curl, G. Richard, MD ; Dryjski, Maciej L., MD, PhD</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c451t-82a45fe873496ef17fe14d0d6429fcc8bb5302e3d10e6397beaead20d9cb4e873</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2017</creationdate><topic>Academic Medical Centers - economics</topic><topic>Aged</topic><topic>Aged, 80 and over</topic><topic>Aortic Aneurysm, Abdominal - diagnostic imaging</topic><topic>Aortic Aneurysm, Abdominal - economics</topic><topic>Aortic Aneurysm, Abdominal - mortality</topic><topic>Aortic Aneurysm, Abdominal - surgery</topic><topic>Blood Vessel Prosthesis - economics</topic><topic>Blood Vessel Prosthesis Implantation - adverse effects</topic><topic>Blood Vessel Prosthesis Implantation - economics</topic><topic>Blood Vessel Prosthesis Implantation - instrumentation</topic><topic>Blood Vessel Prosthesis Implantation - mortality</topic><topic>Chi-Square Distribution</topic><topic>Cost Savings</topic><topic>Cost-Benefit Analysis</topic><topic>Disease-Free Survival</topic><topic>Endovascular Procedures - adverse effects</topic><topic>Endovascular Procedures - economics</topic><topic>Endovascular Procedures - instrumentation</topic><topic>Endovascular Procedures - mortality</topic><topic>Female</topic><topic>Hospital Costs</topic><topic>Humans</topic><topic>Kaplan-Meier Estimate</topic><topic>Male</topic><topic>Middle Aged</topic><topic>New York</topic><topic>Postoperative Complications - economics</topic><topic>Postoperative Complications - etiology</topic><topic>Postoperative Complications - therapy</topic><topic>Prosthesis Design</topic><topic>Retreatment - economics</topic><topic>Retrospective Studies</topic><topic>Risk Factors</topic><topic>Surgery</topic><topic>Time Factors</topic><topic>Treatment Outcome</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>O'Brien-Irr, Monica S., MS, RN</creatorcontrib><creatorcontrib>Harris, Linda M., MD</creatorcontrib><creatorcontrib>Dosluoglu, Hasan H., MD</creatorcontrib><creatorcontrib>Cherr, Gregory S., MD</creatorcontrib><creatorcontrib>Rivero, Mariel, MD</creatorcontrib><creatorcontrib>Noor, Sonya, MD</creatorcontrib><creatorcontrib>Curl, G. Richard, MD</creatorcontrib><creatorcontrib>Dryjski, Maciej L., MD, PhD</creatorcontrib><collection>ScienceDirect Open Access Titles</collection><collection>Elsevier:ScienceDirect:Open Access</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Journal of vascular surgery</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>O'Brien-Irr, Monica S., MS, RN</au><au>Harris, Linda M., MD</au><au>Dosluoglu, Hasan H., MD</au><au>Cherr, Gregory S., MD</au><au>Rivero, Mariel, MD</au><au>Noor, Sonya, MD</au><au>Curl, G. Richard, MD</au><au>Dryjski, Maciej L., MD, PhD</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Factors that affect cost and clinical outcome of endovascular aortic repair for abdominal aortic aneurysm</atitle><jtitle>Journal of vascular surgery</jtitle><addtitle>J Vasc Surg</addtitle><date>2017-04-01</date><risdate>2017</risdate><volume>65</volume><issue>4</issue><spage>997</spage><epage>1005</epage><pages>997-1005</pages><issn>0741-5214</issn><eissn>1097-6809</eissn><abstract><![CDATA[Abstract Objective This study evaluated the effect of indication for use (IFU), additional graft components, and percutaneous closure of endovascular aortic repair (PEVAR) on clinical outcomes and cost of endovascular aortic repair (EVAR). Methods Clinical and financial data were obtained for all elective EVARs completed at a university-affiliated medical center between January 2012 and June 2013. Data were analyzed by χ2 , Student t -test for independent samples, and Kaplan-Meier survival. Results There were 67 elective EVARs. Additional cuffs/extensions were used in 37%, increasing the baseline graft cost by 36% ( P < .001), total costs by 20% ( P < .001), and negatively affecting the contribution margin. Aortic neck IFU ( P = .02), failure of the index graft to seal the neck ( P = .02), and need for an additional cuff ( P = .008) were related to the need for reintervention for type Ia endoleak for graft B (Excluder; W. L. Gore and Associates, Flagstaff, Ariz), whereas limb IFU was related to the need for additional limb extension for graft A (Powerlink; Endologix, Irvine, Calif; P < .001). Limb extension ( P = .06) and failure of the index graft to provide an adequate seal ( P < .001) were associated with reintervention for type Ib endoleak. Reintervention-free rates at 24 months were 96% for graft A and 94% for graft B ( P =.54), but different patterns in reintervention emerged: graft A required reoperation early (<2 months) then stabilized; graft B did not require reintervention until 24 months, but rates increased substantially by 25 months. PEVAR was attempted in 61 (91%): 49 (73%) bilaterally, 7 (10%) unilaterally, and 5 (8%) failed. The mean number of closure devices was four (range, 1-9): $1000 (3.5% of total cost). Bilateral PEVAR was associated with shorter operating time than unilateral PEVAR/failed PEVAR ( P < .001) and lower operating room use costs ( P = .005) and total hospital costs ( P = .003) than failed PEVAR. The contribution margin was higher for bilateral PEVAR than unilateral PEVAR/failed PEVAR ( P = .005). Patients with bilateral PEVAR and unilateral PEVAR were more often discharged on postoperative day 1 than those with failed PEVAR ( P = .002). Hospital length of stay ( P = .49), operating room duration ( P = .31), and total costs ( P = .72) were similar for unsuccessful PEVAR and EVAR completed with cutdown. Conclusions Higher rates of reintervention occurred when EVAR was performed outside of IFU guidelines or when additional components were needed. Additions raised graft costs significantly above baseline. Notable differences in graft performance in complex anatomy and varied patterns of reoperation could be useful in the graft selection process to improve outcome and contain costs. Bilateral PEVAR was associated with lower costs and postoperative day 1 discharge. Attempting PEVAR may be reasonable unless there is serious concern for failure.]]></abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>28034587</pmid><doi>10.1016/j.jvs.2016.08.090</doi><tpages>9</tpages><oa>free_for_read</oa></addata></record> |
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| identifier | ISSN: 0741-5214 |
| ispartof | Journal of vascular surgery, 2017-04, Vol.65 (4), p.997-1005 |
| issn | 0741-5214 1097-6809 |
| language | eng |
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| source | BACON - Elsevier - GLOBAL_SCIENCEDIRECT-OPENACCESS |
| subjects | Academic Medical Centers - economics Aged Aged, 80 and over Aortic Aneurysm, Abdominal - diagnostic imaging Aortic Aneurysm, Abdominal - economics Aortic Aneurysm, Abdominal - mortality Aortic Aneurysm, Abdominal - surgery Blood Vessel Prosthesis - economics Blood Vessel Prosthesis Implantation - adverse effects Blood Vessel Prosthesis Implantation - economics Blood Vessel Prosthesis Implantation - instrumentation Blood Vessel Prosthesis Implantation - mortality Chi-Square Distribution Cost Savings Cost-Benefit Analysis Disease-Free Survival Endovascular Procedures - adverse effects Endovascular Procedures - economics Endovascular Procedures - instrumentation Endovascular Procedures - mortality Female Hospital Costs Humans Kaplan-Meier Estimate Male Middle Aged New York Postoperative Complications - economics Postoperative Complications - etiology Postoperative Complications - therapy Prosthesis Design Retreatment - economics Retrospective Studies Risk Factors Surgery Time Factors Treatment Outcome |
| title | Factors that affect cost and clinical outcome of endovascular aortic repair for abdominal aortic aneurysm |
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